Which nursing action is priority when a patient who presents to the ED with an indirect injury to the head has an ICP of 18 mm Hg?

Which nursing action is priority when a patient who presents to the ED with an indirect injury to the head has an ICP of 18 mm Hg?

• A. Administer diuretic
• B. Prepare for surgery
• C. Notify the health care provider
• D. Continue observation

Answer: (C)

Elevated intracranial pressure in head injury requires rapid clinician involvement. An ICP of 18 mm Hg is above normal and signals potential brain swelling that can worsen quickly if not addressed. The nurse’s priority is to notify the health care provider so that orders can be made for assessment and appropriate intervention to prevent further injury, such as imaging, airway and hemodynamic management, or medications to reduce ICP. Without orders, implementing treatments like diuretics or moving toward surgery isn’t appropriate. Observation alone won’t reverse the rising pressure, and early escalation allows the team to act promptly to protect cerebral perfusion and prevent deterioration.

Elevated intracranial pressure in head injury requires rapid clinician involvement. An ICP of 18 mm Hg is above normal and signals potential brain swelling that can worsen quickly if not addressed. The nurse’s priority is to notify the health care provider so that orders can be made for assessment and appropriate intervention to prevent further injury, such as imaging, airway and hemodynamic management, or medications to reduce ICP. Without orders, implementing treatments like diuretics or moving toward surgery isn’t appropriate. Observation alone won’t reverse the rising pressure, and early escalation allows the team to act promptly to protect cerebral perfusion and prevent deterioration.